Basic Information
| Provider Information | |||||||||
| NPI: | 1073893251 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILLENWATER | ||||||||
| FirstName: | JAMIE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 W 3RD ST | ||||||||
| Address2: | |||||||||
| City: | SHERIDAN | ||||||||
| State: | WY | ||||||||
| PostalCode: | 828013606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076722092 | ||||||||
| FaxNumber: | 3076731969 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 W 3RD ST | ||||||||
| Address2: | |||||||||
| City: | SHERIDAN | ||||||||
| State: | WY | ||||||||
| PostalCode: | 828013606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076722092 | ||||||||
| FaxNumber: | 3076731969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2011 | ||||||||
| LastUpdateDate: | 10/04/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT-1386 | WY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.